Fill and Sign the Surgery Waiver Form

Consent to Surgery and Waiver and Release of Hospital and Staff Consent and release executed by _________________ (Name of Patient) of _____________________________________________________________________ (street address, city, state, zip code) , hereinafter referred to a Releasor , to and in favor of ___________________________ (Name of Hospital) , a nonprofit corporation with its principal office located at ___________________________________________ ______________________________ (street address, city, state, zip code) , referred to herein as Hospital , including, its directors, medical and surgical staff, agents, employees and any other person connected with the surgery to be performed on Releasor with his/her consent. Releasor understands and agrees that: 1. After extensive medical testing and diagnoses, it is the opinion of the medical staff of Hospital that Releasor is suffering from ______________________________ (name of disease or condition) that has arisen as a result of ___________________ ___________________________________________________________ (describe) . 2. Releasor faces the possibility of death or serious disability unless surgery described generally as follows is performed without delay: ______________________ ________________________________________________ (description of surgery) . 3. Releasor has been advised by _____________________ (Name of Physician) , a member of the professional staff of Hospital, as to the dangers associated with, and possible complications from, such surgery. 4. Certain resident physicians and surgeons at Hospital are qualified and willing to perform the surgery. 5. Before such surgery will be performed, Releasor must consent to the surgery and must release the physicians and surgeons who propose to perform the surgery, as well as Hospital and its medical staff, agents and employees, from all liability that may result from the surgery. 6. In consideration of the surgery to be performed and any further surgery that may, in the opinion of the medical staff of Hospital be necessary, Releasor, fully realizing that such surgery may be unsuccessful, that it may have certain complications, including, but not limited to ___________________________________________________ (list) , and that possible results of such complications are ____________________________ ______________________________________ (list) , requests that such surgery be performed, and consents to the surgery. Releasor releases and forever discharges Hospital, its directors, medical and surgical staff, agents, employees and any other persons connected with such surgery, from all claims, damages and causes of action that may arise from the surgery described in this release, and from other medical care arising from the same, including post-surgical treatment while Releasor remains a patient at Hospital. 7. Releasor agrees that no representations have been made regarding the success of this surgery to Releasor, except as set forth in this Consent and Release. 8. This Release shall be binding on ______________________ (Name of Patient) , as Releasor, and on the heirs, legal representatives and assigns of Releasor. 9. Releasor has read all the terms of this instrument and understands that he/she is signing a complete release and bar to any claim resulting from the surgery described in this Consent to Surgery and Waiver and Release. Releasor has executed this release this the _____ day of ________________, 20_____. ______________________________ _____________________________ (Printed Name of Witness) (Printed Name of Patient) ______________________________ _____________________________ (Signature of Witness) (Signature of Patient) Parent or Guardian must sign if Patient is under 18 years of age. I, as parent or guardian of the above named Patient agree individually and on behalf of my child or ward, to the terms of the above Consent to Surgery and Waiver and Release . WITNESS my signature on this the ____ day of ____________, 20_____. __________________________ __________________________________ (Printed Name of Witness) (Printed Name of Parent or Guardian) __________________________ _________________________________ (Signature of Witness) (Signature of Parent or Guardian)